Rhuem and ortho surg

Question 1

67 YO man. back pain 2 days. moving boxes in garage when started.

not relieved by lying down and increases in intensity when straining or coughing

point tenderness along midline vertebra

most likely diagnosis?

Answer 1

loss of bone mineral density!!! = acute vertebral compression fracture!!

Can be caused by twisting, lifting or other minimal trauma eg coughing.

presents with back pain and vertebral point tenderness

associated with decreased bone mineral density. age >65 rf for osteoporosis

NOT ligamentous sprain as typically relieved with rest and tenderness located at the paraspinal tissues!

Question 2

Median nerve affects lateral 3.5 digits and thuMb abduction!

Question 3

corticosteroid joint injection to shoulder, returns with increased pain and swelling, restricted range of motion.

first step in management?

Answer 3

image guided aspiration!!

septic bursitis most likely due to introduction of skin flora

Question 4

using succinylcholine as an anaesthetic in a patient with fractures carries the risk of what?

what should you use instead

Answer 4

hyperkalemia and resulting cardiac arrythmia!!

also seen in burns patients and stroke patients

non depolarizing neuromuscular blocking agents eg vecuronium, rocuronium.

Question 5

septic arthritis, after antibiotics, further treatment is?

Answer 5

irrigation and drainage!!

Question 6

Pain control that has not been achieved using other methods in a patient with a history of opioid use disorder. eg pain only gone down to 7/10 next step in management?

Answer 6

IV short acting opiods eg methadone

Question 7

lump on right hand. on examination, fibrous nodular band at base of ring finger. history of T2DM.

most likely cause?

Answer 7

fibrosis of palmar fascia!!! = may progress to dupyntrens contracture

Question 8

pediatric osteomyeletis = fever, refusal to weight bear, typically affects metaphysis of long bones

Question 9

5 year old boy, limited left wrist motion and impaired thumb movement. X ray showded a buckle fracture of radius. diagnosis = incomplete radial fracture!!

Question 10

burning sensation from medial heel radiating to toes in a runner. dorsiflexion eversion and plantar flexion inversion reproduce the pain

most likely diagnosis??

Answer 10

Tarsal tunnel syndrome!!!! -> affects the posterior tibial nerve that runs through the medial ankle!! recreate symptoms by tapping on nerve/tinels sign

NOT calcaneal apophysisitis as pain localised to heel and achilles tendon insertion site

not calcaneal stress fracture which can be caused by running as pain is localised to heel and can be elicited by squeezing medial and lateral calcaneus

NOT plantar fasciitis as although it causes plantar pain particularly medio-plantar region of foot where the plantar aponeurosis inserts into the calcaneus, pain is typically increased by dorsiflexion of the toes and palpation between heel and forefoot!!! heel inserts help. calcaneal spurs incidental. pain at sole of foot worse with weight bearing

NOT tibialis anterior tendinopathy as presents as anterior ankle pain that worsens with dorsiflexion

Question 11

tibial fracture 8 months ago. intermittent pain and sinus tract formation. x ray shows non union.

most likely diagnosis?
management?

Answer 11

chronic osteomyelitis!!

surgical debridement and bone biopsy!!!

Question 12

12 yo boy, fracture of distal tibia epiphysis. most likely complication?

Answer 12

limb length discrepancy!

Question 13

53 yo man. right sided lateral hip pain. worse with hip flexion eg climbing stairs, going up hill, getting out of car or lying on affected sign.

pain worse with prolonged standing or activity.

tenderness over lateral right hip and buttock with palpation

most likely diagnosis?

management??

Answer 13

greater trochanteric pain syndrome/ trochanteric bursitis!!!! = local corticosteroid injections!!! and nsaids NOT opiods like hydrocone

NOT meralgia paraesthetica as this affects the mid lateral thigh and not hip. caused by compression of lateral femoral cutaneous nerve

Question 14

indications for open reduction and surgical fixation rather than closed reduction for a humeral fracture?

Answer 14

1. significant displacement - evidenced by arm shortening!!
2. neurovascular compromise - assymettric radial pulses!!!
3. open fractures

Question 15

new onset left hip pain, restriction of abduction and internal rotation of hip. history of sickle cell. new sexual partner.

most likely diagnosis?

Answer 15

osteonecrosis of proximal femur!!! = avascular necrosis

not gonorrhea as infection of distal large joints eg knees and ankles more common

Question 16

What type of hip dislocation is common in MV accidents? leg shortened and internally rotated. impaired dorsiflexion due to sciatic nerve injury

Answer 16

POSTERIOR

Question 17

17 yo. kicked in thigh during soccer match. recurrent pain after initial reslvement of pain 4 weeks ago.

3cm mobile mass in thigh

Answer 17

heterotopic bone formation in tissues!!!! = myositis ossificans!!!!

triggered by trauma -> quadriceps and brachialis most common

xray may show calcification with radiolucent zones

alk phos and esr may be raised

NOT a quadricpes muscle tear as this presents with decreased knee extension and palpable defect above patella with patella riding low!!!! and can hear a pop with swelling when injured!

Question 18

Clavicular fracture seen on CXR following trauma. next step in workup?

signs of vascular injury eg hypotension, hematoma, reduced pulse, next step in work up?

hard signs of vascular injury eg absent pusles, distal ischemia, next step in management?

Answer 18

CT of CHEST! To rule out intrathoracic injury - subclavian vessels

CT angiography!!!

urgent surgical exploration!!

Question 19

What is the indication for an ankle xray following an ankle injury?

Answer 19

pain PLUS

1. Tenderness of lateral or medial malleolus

OR

2. inability to weight bear

helps to distinguish sprain from fracture

similar rules for x ray of foot

Question 20

Adhesive capsulitis symptoms?

management?

note adhesive capsulitis = adhesions and fibrosis of shoulder joint synovial lining

Answer 20

shoulder pain and increasing stiffness. reduced active and passive range of movement in all planes (abduction, flexion, internal external rotation)

severe cases = deltoid muscle atrophy, loss of arm swing during ambulation

xrays typically normal

ROM EXERCISES!!!
intraarticular steroids, nsaids

Question 21

Posterior hip dislocation presents with adduction and INTERNAL rotation of knee (almost like valgum)
(Think of it as moving back and in!!!)

how does a femoral neck fracture present??

Answer 21

leg shortened, ABDUCTED, EXTERNALLY ROTATED. “outside”

need to know difference!!

Question 22

Pagets increases risk of osteosarcoma. periosteal elevation/codmans triangle, sunburst periosteal pattern (concentric areas of reactive bone)

osteosarcoma linked to retinoblastomas and li fraumeni syndrome

Question 23

patella dislocation presentation?

Answer 23

flexed knee with reduced ROM and lateral displacement of patella out of trochlea

popping sound may be heard

Question 24

38 yo man. progressive right hip pain. pain in the groin, worsens with weight bearing. forced abduction and internal rotation aggravate pain (restricted ROM)

history of sarcoidosis on oral glucocorticoids

round face and fullnesss in supraclavicular area (dorsocervical fat pad)

most likely cause?

Answer 24

disruption of bone vasculature!!! = avascular necrosis or osteonecrosis of femoral head

glucocorticoid/steroid use = key risk factor!!!! also excessive alcohol!!!!!

pain in groin thigh or buttocks that worsens with activity. reduced ROM with progression. x ray usually normal. MRI more sensitive

Question 25

17 yo girl. right knee pain worse with weight bearing on knee eg squatting, climbing up and down stairs, or running or sitting. knee may feel like its giving way compressing patella into trochlear groove with knee extended can reproduce symptoms most likely diagnosis? management?

Answer 25

Patellofemoral pain syndrome!!! quadriceps strengthening exercises!!! = also used in arthritis!

Question 26

post amputation, focal tenderness and when pressure applied to stump, pain radiating up limb. thus difficult to fit prosthesis. pain decreases with anaethetic injection most likely diagnosis? management?

Answer 26

post-traumatic neuroma!!!!! -> excision! +/- steroids!!! phantom limb pain = starts within 1 week, intermittent cramping and burning. not elicited by joint palpation -> multimodar pain regimen acute stump pain = severe pain lasting 1-3 weeks ischemic pain = swelling, skin discolouration, wound breakdown.

Question 27

patient with tibial tress fracture and BMI of 17. Expresses distress at having to limit physical activity next step in management?

Answer 27

comprehensive dietary history! assess for anorexia nervosa

Question 28

posterior shoulder dislocation first step in management? if patient later post management has limited abduction due to pain but no numbness or changes in sensation most likely diagnosis?

Answer 28

closed reduction in emergency department!! NOT CT angiogram as used in signs of limb ischemia eg absent distant pulses and expanding hematoma rotator cuff injury!! -> pain and decreased abduction -> MRI!!! as not seen on x ray. may also have decreased external rotation. positive drop arm test axillary nerve damage will have all of this PLUS sensory loss over lateral shoulder

Question 29

first step in work up for socliosis? red flags in scoliosis that require further work up?

Answer 29

x ray of spine!! -> to determine degree of curvature/ back pain, neurologic symptoms, rapidly progressing curvature, vertebral anomalies on xray !!!!! tumour, infection, trauma

Question 30

in patients with unstable medical conditions eg syncope, heart failure, hip fracture surgery can be delayed for up to 72 hours for workup -> ECG, cardiac markers, CXR

Question 31

shoulder injury tackling partner in rugby. ADDUCTION of right arm across torso elicits pain over superior shoulder. xrays normal and ROM normal.

Answer 31

acromioclavicular joint sprain!!! tenderness over AC joint can occur

Question 32

displaced supracondylar fractures of humerus pose greatest risk to what structures?

Answer 32

brachial artery!!!!! median nerve!!!

Question 33

compartment pressures can be normal BUT compartment syndrome can arise later despite this!!! due to reperfusion. signs include tense swelling, pain with manipulation can occur in arm eg due to prolonged compression following falls injury

Question 34

adhesive capsulitis = decreased active and passive ROM rotator cuff tear = weakness with abduction and external rotation rotator cuff impingement/tendinopathy = similar to above PLUS positive impingement test biceps tendinopathy/ rupture = anterior shoulder pain. pain with lifting/overhead reaching glenohumeral OA = rare, caused by trauma. decreased active and passive abduction and external rotation.

Question 35

shoulder pain + positive impingement test. most likely cause?

Answer 35

inflammation of rotator cuff tendons = rotator cuff tendinopathy!!!

Question 36

MUST have tenderness over tibial tubercle to diagnose osgood schlattters

Question 37

13 yo chronic knee pain noticed during sports weight at 95th percentile!!!! walks with a limp with right foot pointed laterally (externally rotated) most likley diagnosis?

Answer 37

SUFE!!! Reffered knee pain commonly only symptom!!! or referred thigh pain

Question 38

displaced scaphoid frature wrist = surgical intervention nondisplaced = cast + serial x rays for osteonecrosis and non union

Question 39

flexor carpi radialis tensonovitis = excessive wrist flexion + pain and tenderness over anterior aspect of wrist trigger thumb - pain over palmar aspect of thumb locking in flexion of thumb

Question 40

hemodynamically unstable, xray shows pelvic fracture. following fluid resus, first step in management?

Answer 40

placement of pelvic binder to stop hemorrhage!! CT scan of abdomen laterr as is retrograde cystourethrogram

Question 41

picture of obvious prepatellar bursitis PLUS erythema, warmth, fever, pain most likely diagnosis? first step in management?

Answer 41

septic bursitis!!! diagnostic aspiration of bursal fluid!!! systemic antibiotics

Question 42

following a knee dislocation, most important next step in management? why?

Answer 42

measure ABPI!!! - Prompt arteriography is also important!!!!! Was The answer in NBME paper Risk of limb threatening popliteal artery injury!! nerve conduction test on only if signs eg foot drop, concerning for peroneal nerve injury

Question 43

chronic exertional compartment syndrome -> long distance runners. lower leg muscle pain that stops within 20 minutes of stopping activity interosseous ligament tear = ankle sprain medial tibial stress syndrome (shin splits) = diffuse painful are over tibial shaft rather than point tenderness note XRAYS are frequently normal in tibial stress fractures!!!! and the fracture causes point tenderness. tibialis anterior tendinopathy = pain over greater area along the tibia, worsens with resisted dorsiflexion!! hill training = rf

Question 44

acute knee pain with intermittent catching, reduced extension and flexion and extension of knee when held in internal and external rotation causing pain and creptius (positive mc murrays test) most likely diagnosis? first step in management?

Answer 44

meniscal tear!!! MRI of knee!!

Question 45

groin pain and restricted range of motion in a 37 YO man. xray showing osteonecrosis of femoral head. most likely contributing factor in this mans case was excessive alcohol use!!!!! it wasnt corticosteroid use as patient was only on a single short course of pred for 5 days a year ago

Question 46

next step in management of suspected calcaneal stress fracture?

Answer 46

xray!!!!

Question 47

how does a ruptured popliteal cyst present?

Answer 47

posterior knee and calf pain tenderness and swelling of calf arch of echymosis distal to medial mallelous -> crescent sign US rules out DVT

Question 48

osteochondroma - benign spurs often palpable on exam. xray of limb shows projecting lesions. cortex of lesions continous with cortex of surrounding bone

Question 49

Injury to radial nerve ABOVE The elbow not at the elbow, occur s with distal humerus fractures

Question 50

Shows a picture of someone heel. X-ray shows calcaneal spur. Patient has pain when he stands up and walks after sitting. Palpation of medial plantar surface of heel increases pain. Most likely diagnosis?

Answer 50

Plantar fasciitis!!!! Classic presentation Often associated with calcaneal spurs!!!!